A client is in the acute phase of a burn injury. The nurse notes a Mean Arterial Pressure (MAP) of 74 mm Hg, urine output of 95 mL/hr, and a temperature of 38.6°C (101.5°F). The white blood cell (WBC) count is 18,000/mm and the burn wound has increased drainage with a foul odor.
What is the priority nursing action?

Encourage increased oral protein intake.

Administer prescribed opioid analgesic.

Reduce IV fluid infusion rate.

Notify the provider and obtain wound and blood cultures.

Answer and Explanation

The Correct Answer is D

Management of burn injuries involves monitoring for systemic complications like sepsis. This scenario requires applying knowledge of systemic inflammatory response syndrome (SIRS) and infection indicators to prioritize interventions when clinical data suggest the onset of a life-threatening wound infection.

Choice A rationale

While increased protein intake is vital for wound healing during the hypermetabolic state of a burn injury, it is not the priority when a client shows active signs of systemic infection and potential sepsis requiring immediate medical intervention.

Choice B rationale

Pain management is a core component of burn care. However, the presence of fever, tachycardia, high WBC count (normal 5,000 to 10,000/mm), and foul-smelling drainage indicates a systemic infection that takes priority over routine analgesic administration for stability.

Choice C rationale

Reducing the IV fluid rate could be dangerous. In the acute phase of burns, maintaining adequate perfusion is critical. Given the signs of infection, the patient may need more fluid to support hemodynamics if they are entering septic shock.

Choice D rationale

The client exhibits classic signs of sepsis, including fever, leukocytosis, and localized wound infection symptoms. The priority is to notify the provider and obtain cultures to identify the pathogen and initiate appropriate antibiotic therapy immediately to save lives..

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Free Nursing Study Resources

Correct Answer is A

Explanation

Pancreatitis often leads to electrolyte imbalances, specifically hypocalcemia due to fat necrosis and soap formation. Knowledge of cardiac electrophysiology is required to recognize how low calcium levels (normal 8.5 to 10.5 mg/dL) affect the myocardial action potential.

Choice A rationale

Prolonged QT interval is a classic electrocardiogram finding in hypocalcemia. Low serum calcium slows the movement of calcium into the cardiac cells during the plateau phase, thereby lengthening the duration of ventricular depolarization and repolarization cycles.

Choice B rationale

A shortened PR interval is not associated with hypocalcemia. PR interval changes are more frequently linked to pre-excitation syndromes or inflammatory conditions of the heart, rather than the specific electrolyte shifts seen in acute pancreatic inflammation.

Choice C rationale

Peaked T waves are a hallmark sign of hyperkalemia, not hypocalcemia. In hypocalcemia, the T wave may actually appear flattened or inverted, but the most distinctive and supportive finding remains the elongation of the QT interval.

Choice D rationale

Elevated ST segments are typically indicative of myocardial infarction or pericarditis. While electrolyte imbalances can cause various cardiac changes, ST elevation is not the primary diagnostic indicator used to support a suspicion of clinical hypocalcemia.

Correct Answer is ["13376"]

Explanation

This scenario requires calculating fluid resuscitation requirements for a burn patient. Knowledge of the Parkland formula is necessary to determine the total volume of isotonic crystalloids required based on weight and the percentage of total body surface area burned.

Step 1 is 4 mL × 88 kg × 38 percent.

Step 2 is 352 × 38.

Step 3 is 13376 mL.

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Naxlex Comprehensive Predictor Exams

The nurse suspects that a client with pancreatitis has developed hypocalcemia. Which electrocardiogram finding supports the nurse's suspicion?

Correct Answer is A

Explanation

An adult weighing 88 kg is brought to the emergency department after sustaining a thermal injury. Burns are partial and full thickness over 38 According to the Parkland formula, what would this client's fluid requirements be for the first 24 hours after injury?

Correct Answer is ["13376"]

Explanation

The charge nurse supervises unlicensed assistive personnel in the post-stroke rehabilitation unit. Which action by the unlicensed assistive personnel requires immediate intervention by the nurse?

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

The new graduate nurse asks the experienced nurse, Why does a client receive vasopressin after undergoing a hypophysectomy? How should the nurse respond?

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